Comparison of the efficacy of ketamine- propofol versus sodium thiopental-fentanyl in sedation: a randomised clinical trial.

BACKGROUND: Many sedative regimens have been studied with controversial efficiencies. This study tried to assess the desirable and adverse effects of sodium thiopental-fentanyl (TF) with ketamine-propofol (KP) for procedural sedation and analgesia in the emergency department. METHODS: After signing written consent, patients were enrolled in this randomised double-blind trial to receive either KP or TF to reach the desired sedation level. The respiratory and haemodynamic complications, nausea and vomiting, recovery agitation, patient recall and satisfaction, provider satisfaction and recovery time were compared. RESULTS: Of the participants, 47 in the KP group and 49 in the TF group were enrolled. The mean and SD scores were 6.91±1.93 and 8.34±1.25 for patients' satisfaction and 7.55±1.54 and 8.65±1.00 for satisfaction of physicians performing the procedures in TF and KP groups, respectively (p=0.000). Moreover, 39 (79.59%) and 18 (38.29%) of patients declared that they had recalled the procedures in the TF and KP groups, respectively (p=0.000). Transient hypoxia was reported in 2.1% and 8.1% in the KP and TF groups leading to perform 4.2% vs 8.1% airway manoeuvres, respectively, without the need for endotracheal intubation or further admission. CONCLUSIONS: KP and TF combinations were effectively comparable although KP resulted in higher patient and provider satisfaction. This study did not detect a difference regarding adverse respiratory or haemodynamic effects. It is estimated that the TF combination can be potent and efficacious with possible low adverse events in procedural sedation.

Unilateral sixth nerve palsy.

BACKGROUND: The diagnosis of cerebral venous sinus thrombosis still remains a real challenge. Seizure, unusual headache with sudden onset, unexplained persistently unilateral vascular headache and neurologic deficit-which is difficult to be attributed to a vascular territory are some of the suggestive symptoms. CASE: An isolated sixth nerve palsy is discussed as a rare presentation for cerebral venous thrombosis. Following the extensive investigation to rule out other possible diagnoses, magnetic resonance venogram revealed the final etiology of sixth nerve palsy that was ipsilateral left transverse sinus thrombosis; therefore, anticoagulant treatment with low molecular weight heparin was administered. CONCLUSION: Rapid and accurate diagnosis and treatment cause to achieve excellent outcomes for most patients. Considering different clinical features, risk factors and high index of suspicion are helpful to reach the diagnosis.

Comparison of Emergency Echocardiographic Results between Cardiologists and an Emergency Medicine Resident in Acute Coronary Syndrome.

INTRODUCTION: Early detection of regional wall motion abnormality (RWMA) can be a reliable tool for rapid disposition of patients with acute coronary syndrome (ACS) in the emergency department. In this study, the diagnostic accuracy of point-of-care echocardiography performed by a trained emergency medicine resident was evaluated in comparison with board-certified cardiologists. METHODS: A prospective, cross-sectional study was implemented on adult patients with ACS. A trained emergency medicine (EM) PGY-3 resident performed point-of-care echocardiography under the supervision of two cardiologists and the reports were compared with cardiologists as a reference test. RESULTS: 100 patients with the mean age of 54.1 ± 11.5 years were recruited (65% male). Based on Thrombolysis in Myocardial Infarction (TIMI) and History, EKG, Age, Risk factors, and troponin (HEART) scores, 43.0% and 25.0% of patients were categorized as low-risk for ACS, respectively. The absolute measure of agreement between cardiologists to determine ejection fraction (EF) was 0.829 (95% CI: 0.74-0.89) based on intraclass correlation coefficient (ICC) estimation. The measurements of agreement between specialists and the EM resident based on the analysis of Kappa coefficient were 0.677 and 0.884 for RWMA and pericardial effusion, respectively. Moreover, 25 patients were in the-low risk group according to the HEART score with an agreement rate of 92% for the lack of RWMA between the EM resident and cardiologists. CONCLUSION: This study found acceptable agreement between the EM resident and cardiologists in assessing RWMA in different ACS risk groups. In addition, there was acceptable agreement between the EM resident and cardiologists in determining left ventricular ejection fraction (LVEF) and pericardial effusion.

The validity of recognition of stroke in the emergency room (ROSIER) scale in the diagnosis of Iranian patients with acute ischemic stroke in the emergency department.

OBJECTIVES: In this study, we aimed to investigate the accuracy of recognition of stroke in the Emergency Room (ROSIER) Scale in the diagnosis of patients with acute ischemic stroke (AIS) transferred to the emergency department (ED). METHODS: The present study was a multicenter study. Records from patients suspected of stroke, who referred to the ED were reviewed. Demographic, clinical, and diagnostic data were extracted and then entered in checklists. ROSIER Scale was used to evaluate the possible diagnosis in this study. The definitive diagnosis of a stroke was made based on neurologist's assessment and clinical and neuroimaging findings, mainly brain magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was conducted for assessing the accuracy of ROSIER in discrimination of stroke. RESULTS: The data of 356 suspected stroke patients were analyzed. Of all, 186 patients (52.2%) were male, and the mean age was 65.2 (standard deviation = 14.0) years ranging from 26 to 95 years. One hundred and fifty-one patients (42.4%) had AIS based on the final diagnosis. The area under the ROC curve was 0.85. The best cutoff point for ROSIER scale was ≥1 with a sensitivity of 85.4% (95% confidence interval [CI]: 78.8, 90.6%) and specificity of 65.8% (95% CI: 58.9, 72.3%). CONCLUSION: Based on the findings, although the best cutoff point was the same as the original (derivation) study, its sensitivity (85.4% vs. 92%) and specificity (65.8% vs. 86%) were considerably lower.

Effects of Renin-Angiotensin-Aldosterone Inhibitors on Early Outcomes of Hypertensive COVID-19 Patients: A Randomized Triple-Blind Clinical Trial.

BACKGROUND: The role of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) has been addressed in some studies related to the current coronavirus disease-2019 (COVID-19) pandemic with possible higher severity and mortality in patients with hypertension. A triple-blind randomized controlled trial was designed to evaluate the effects of these medications on the COVID-19 progression. METHODS: Patients were enrolled in this trial between April and September 2020. They were randomized in 2 groups. The former dosage of ACEis/ARBs was continued in one group while in another group, the ACEis/ARBs were replaced by amlodipine ± carvedilol according to the dose equivalents. The primary outcomes were length of stay in hospitals and intensive care units (ICUs). Other outcomes include mechanical ventilation, noninvasive ventilation, readmission, and COVID-19 symptoms after discharge. RESULTS: We randomized 64 patients with COVID-19 into 2 groups. Most patients were aged 66-80 and 46-65 years-old, 33 (51.6%) and 27 (42.2%), respectively. The study groups were nearly similar in baseline vital signs and characteristics. In addition, there was no significant difference in terms of recorded systolic and diastolic blood pressure measurements between groups. Furthermore, we did not find a significant difference between the days of ICU or ward admission, the discharge rate, or readmission rates between the 2 groups. CONCLUSIONS: This randomized triple-blind multicentric clinical trial did not show any deleterious effects of ACEi/ARB medications in hypertensive COVID-19 patients. CLINICAL TRIALS REGISTRATION: The trial acquired the ethical code, IR.TUMS.VCR.REC.1399.028 and was registered in the Iranian randomized controlled trial system (registration no. IRCT20151113025025N3), https://en.irct.ir/trial/46531.

The assessment of ice pack effect in pain reduction during digital nerve block: A randomized clinical study.

OBJECTIVES: Digital nerve block is a painful procedure. Several methods have been proposed to decrease the injection pain. Applying an ice pack is a pertinent choice due to its effectiveness on pain reduction, convenience, and low costs. In this study, the degree of injection pain reduction was assessed after applying an ice pack to the site of anesthetic injection. METHODS: One hundred participants with traumatic finger injury were assessed. Digital nerve block was performed in fifty patients in the intervention group after 6 min of ice application. In the control group, this procedure was done without ice. The primary outcome was the difference between the needle stick and infiltration pain scores with and without ice pack. The secondary outcome the patient satisfaction score. The protocol of this study was approved by the Institutional Review Board, and it is registered in the Iranian Registry of Clinical Trials. RESULTS: The pain score was assessed using a Numeric Rating Scale. Both the needle skin and infiltration pain scores were statistically significantly lower in the intervention group (P < 0.001). The mean and median needle stick pain scores were 1.5 and 1.0 in the intervention group and 6.8 and 7.0 in the control group, respectively. Moreover, the mean and median infiltration pain scores were 2.7 and 2.0 in the intervention group and 8.5 and 9.0 in the control group, respectively. Patient satisfaction score was significantly higher in the intervention group. CONCLUSIONS: Ice pack is inexpensive, readily available, and is easy to apply. We recommend this method to reduce the injection pain before digital nerve block in the emergency department.

Point-of-care ultrasound to complete physical exam and to reach the diagnosis in a young man with syncope.

BACKGROUND: Cardiac syncope can result from an atrial myxoma due to outflow obstruction. Myxoma is the most common primary cardiac tumor that may cause sudden death and the nonspecific symptoms may make early diagnosis difficult. CASE PRESENTATION: A 27-year-old man presented to our emergency department after two episodes of syncope and severe fatigue. He had no complaint of fever, weight loss, sweating, chest pain or dyspnea. Vital signs were within normal limits. A loud heart S1 was detected and normal neck veins. Other systemic examinations including neurological assessment were normal. Electrocardiography showed normal sinus rhythm. An obvious variability in heart rate was noticed on cardiac monitor changing by the patient's position. Point-of-care ultrasonography (PoCUS) showed a large hyperechoic lesion with a well-defined stalk originating from the left atrium (LA). Thus, the patient was transferred to a cardiac surgery center for surgical intervention. Histopathology reported an LA mass compatible with myxoma. CONCLUSIONS: Emergency physicians should be familiar with the vague presentations of cardiac tumors to improve patient outcomes. It is beneficial to take advantage of bedside ultrasound for prompt diagnosis and subsequent treatment.

Low-dose intravenous ketamine versus intravenous ketorolac in pain control in patients with acute renal colic in an emergency setting: a double-blind randomized clinical trial.

BACKGROUND: This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED). METHODS: This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter. RESULTS: The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group. CONCLUSIONS: Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions.

Implementation a Medical Simulation Curriculum in Emergency Medicine Residency Program.

Applying simulation in medical education is becoming more and more popular. The use of simulation in medical training has led to effective learning and safer care for patients. Nowadays educators have confronted with the challenge of respecting patient safety or bedside teaching. There is widespread evidence, supported by robust research, systematic reviews and meta-analysis, on how much effective simulation is. Simulation supports the acquisition of procedural, technical and non-technical skills through repetitive practice with feedbacks. Our plan was to induct simulation in emergency medicine residency program in order to ameliorate our defects in clinical bedside training. Our residents believed that simulation could be effective in their real medical practice. They mentioned that facilitators' expertise and good medical knowledge, was the strongest point of the program and lack of proper facilities was the weakest.

12th WINFOCUS world congress on ultrasound in emergency and critical care.

TABLE OF CONTENTS: A1 Point-of-care ultrasound examination of cervical spine in emergency departmentYahya Acar, Onur Tezel, Necati SalmanA2 A new technique in verifying the placement of a nasogastric tube: obtaining the longitudinal view of nasogastric tube in addition to transverse view with ultrasoundYahya Acar, Necati Salman, Onur Tezel, Erdem CevikA3 Pseudoaneurysm of the femoral artery after cannulation of a central venous line. Should we always use ultrasound in these procedures?Margarita Algaba-Montes, Alberto Oviedo-García, Mayra Patricio-BordomásA4 Ultrasound-guided supraclavicular subclavian vein catheterization. A novel approach in emergency departmentMargarita Algaba-Montes, Alberto Oviedo-García, Mayra Patricio-BordomásA5 Clinical ultrasound in a septic and jaundice patient in the emergency departmentMargarita Algaba-Montes, Alberto Oviedo-García, Mayra Patricio-BordomásA6 Characterization of the eyes in preoperative cataract Saudi patients by using medical diagnostic ultrasoundMustafa Z. Mahmoud, Abdelmoneim SuliemanA7 High-frequency ultrasound in determining the causes of acute shoulder joint painMustafa Z. MahmoudA8 Teaching WINFOCUS Ultrasound Life Support Basic Level 1 for Providers in resource-limited countriesAbbas Ali, Alrayah Mustafa, Ihab Abdelrahman, Mustafa Bahar, Osama Ali, H. Lester Kirchner, Gregor ProsenA9 Changes of arterial stiffness and endothelial function during uncomplicated pregnancyAjda Anzic, Paul LeesonA10 Cardiovascular haemodynamic properties before, during and after pregnancyAjda Anzic, Paul LeesonA11 An old man with generalized weaknessMaryam Bahreini, Fatemeh RasooliA12 Ultrasonography for non-specific presentations of abdominal painMaryam Bahreini, Houman HosseinnejadA13 Introduction of a new imaging guideline for suspected renal colic in the emergency department: effect on CT Urogram utilisationGabriel Blecher, Robert Meek, Diana Egerton-WarburtonA14 Transabdominal ultrasound screening for pancreatic cancer in Croatian military veterans: a retrospective analysis from the first Croatian veteran's hospitalEdina Catic Cuti, Stanko Belina, Tihomir Vancina, Idriz KovacevicA15 The challenge of AAA: unusual case of obstructive jaundiceEdina Catic Cuti, Nadan RustemovicA16 Educational effectiveness of easy-made new simulator model for ultrasound-guided procedures in pediatric patients: vascular access and foreign body managementIkwan Chang, Jin Hee Lee, Young Ho Kwak, Do Kyun KimA17 Detection of uterine rupture by point-of-care ultrasound at emergency department: a case reportChi-Yung Cheng, Hsiu-Yung Pan, Chia-Te KungA18 Abdominal probe in the hands of interns as a relevant diagnostic tool in revealing the cause of heart failureEla Curcic, Ena Pritisanac, Ivo Planinc, Marijana Grgic Medic, Radovan RadonicA19 Needs assessment of the potential utility of point-of-care ultrasound within the Zanzibar health systemAbiola Fasina, Anthony J. Dean, Nova L. Panebianco, Patricia S. HenwoodA20 Ultrasonographic diagnosis of tracheal compressionOliviero Fochi, Moreno Favarato, Ezio BonanomiA21 The role of ultrasound in the detection of lung infiltrates in critically ill patients: a pilot studyMarijana Grgic Medic, Ivan Tomic, Radovan RadonicA22 The SAFER Lasso; a novel approach using point-of-care ultrasound to evaluate patients with abdominal complaints in the emergency departmentYoungrock Ha, Hongchuen TohA23 Awareness and use of clinician-performed ultrasound among clinical clerkship facultyElizabeth Harmon, Wilma Chan, Cameron Baston, Gail Morrison, Frances Shofer, Nova Panebianco, Anthony J. DeanA24 Clinical outcomes in the use of lung ultrasound for the diagnosis of pediatric pneumoniasAngela Hua, Sharon Kim, James TsungA25 Effectiveness of ultrasound in hypotensive patientsIsa Gunaydin, Zeynep Kekec, Mehmet Oguzhan AyA26 Moderate-to-severe left ventricular ejection fraction related to short-term mortality of patients with post-cardiac arrest syndrome after out-of-hospital cardiac arrestJinjoo Kim, Jinhyun Kim, Gyoosung Choi, Dowon ShimA27 Usefulness of abdominal ultrasound for acute pyelonephritis diagnosis after kidney transplantationJi-Han LeeA28 Lung ultrasound for assessing fluid tolerance in severe preeclampsiaJana Ambrozic, Katja Prokselj, Miha LucovnikA29 Optic nerve sheath ultrasound in severe preeclampsiaGabrijela Brzan Simenc, Jana Ambrozic, Miha LucovnikA30 Focused echocardiography monitoring in the postoperative period for non-cardiac patientsAsta Maciuliene, Almantas Maleckas, Algimantas Krisciukaitis, Vytautas Maciulis, Andrius MacasA31 POCUS-guided paediatric upper limb fracture reduction: algorithm, tricks, and tipsSharad MohiteA32 Point-of-care lung ultrasound: a good diagnostic tool for pneumonia in a septic patientZoltan Narancsik, Hugon MozinaA33 A case of undergraduate POCUS (r)evolutionSara Nikolic, Jan Hansel, Rok Petrovcic, Una Mrsic, Gregor ProsenA34 The Graz Summer School for ultrasound: from first contact to bedside application: three-and-a-half-day undergraduate ultrasound training: résumé after two years of continuous developmentSimon Orlob, Markus Lerchbaumer, Niklas Schönegger, Reinhard KaufmannA35 Usefulness of point-of-care ultrasound in the emergency room in a patient with acute abdominal painAlberto Oviedo-García, Margarita Algaba-Montes, Mayra Patricio-BordomásA36 Use of bedside ultrasound in a critically ill patient. A case reportAlberto Oviedo-García, Margarita Algaba-Montes, Mayra Patricio-BordomásA37 Diagnostic yield of clinical echocardiography for the emergency physicianAlberto Oviedo-García, Margarita Algaba-Montes, Mayra Patricio-BordomásA38 Focused cardiac ultrasound in early diagnosis of type A aortic dissection with atypical presentationChun-I Pan, Hsiu-Yung Pan, Chien-Hung WuA39 Detection of imperforated hymen by point-of-care ultrasoundHsiu-yung Pan, Chia-Te KungA40 Developing a point-of-care ultrasound curriculum for pediatric nurse practitioners practicing in the pediatric emergency departmentSarah Pasquale, Stephanie J. Doniger, Sharon Yellin, Gerardo ChiricoloA41 Use of transthoracic echocardiography in emergency setting: patient with mitral valve abscessMaja Potisek, Borut Drnovsek, Bostjan LeskovarA42 A young man with syncopeFatemeh Rasooli, Maryam BahreiniA43 Work-related repetitive use injuries in ultrasound fellowsKristine Robinson, Clara Kraft, Benjamin Moser, Stephen Davis, Shelley Layman, Yusef Sayeed, Joseph MinardiA44 Lung ultrasonography in the evaluation of pneumonia in childrenIrmina Sefic Pasic, Amra Dzananovic, Anes Pasic, Sandra Vegar ZubovicA45 Central venous catheter placement with the ultrasound aid: two years' experience of the Interventional unit, Division of Intensive Care Medicine, KBC ZagrebAna Godan Hauptman, Marijana Grgic Medic, Ivan Tomic, Ana Vujaklija Brajkovic, Jaksa Babel, Marina Peklic, Radovan RadonicA46 Duplicitas casui: two patients admitted due to acute liver failureVedran Radonic, Ivan Tomic, Luka Bielen, Marijana Grgic MedicA47 A pilot survey on an understanding of Bedside Point-of-Care Ultrasound (POCUS) among medical doctors in internal medicine: exposure, perceptions, interest, and barriers to trainingPeh Wee MingA48 Unusual case of defecation syncopeNur hafiza Yezid, Fatahul Laham MohammedA49 A case report of massive pulmonary embolism; a multidisciplinary approachZainal Abidin Huda, Wan Nasarudin Wan Ismail, W.Yus Haniff W.Isa, Hashairi Fauzi, Praveena Seeva, Mohd Zulfakar Mazlan.

An isolated bee sting involving multiple cranial nerves.

Hymenoptera stings are self-limiting events or due to allergic reactions. Sometimes envenomation with Hymenoptera can cause rare complications such as acute encephalopathy, peripheral neuritis, acute renal failure, nephrotic syndrome, silent myocardial infarction, rhabdomyolysis, conjunctivitis, corneal infiltration, lens subluxation, and optic neuropathy. The mechanism of peripheral nervous system damage is not clearly known. In our studied case after bee sting on face between the eyebrows with little erythema and 1 × 1 cm in size, bilateral blindness developed and gradually improved. Lateral movement of eyes was restricted with no pain. Involvement of cranial nerves including II, V, and VI was found. With conservative therapy after a year significant improvement has been achieved.